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Transitional care: personal touch and technology

December 2012

Published in the December 2012 issue of Today’s Hospitalist

IF YOUR HOSPITAL IS LIKE MOST IN THE U.S., you’re trying to figure out how to cut 30-day readmission rates and boost patient satisfaction scores. A new startup from pharma giant Merck & Co., is now putting the finishing touches on a suite of post-discharge services to help hospitals achieve both those goals.

The TransitionAdvantage service is designed to fill the well-known gaps in transitional care: incomplete handoffs to primary care physicians, a “voltage drop” in follow-up care, snafus in medication management, and a lack of coordination between the inpatient and outpatient setting.

Hospitals can sign up for a TransitionAdvantage service that relies on automated voice response or Web tools to fill those gaps for patients with MI, heart failure or pneumonia. But the centerpiece of the service is what Vree Health, the Merck subsidiary that designed and markets the program, calls a “transition liaison.”

Those trained liaisons begin daily health checks with patients before they leave the hospital and continue with daily phone calls for 30 days post-discharge. The liaisons, who serve as health coaches, can triage patient care issues to a nurse or a patient’s outpatient or inpatient physician. All providers and case managers have access to patients’ discharge plans and daily progress via the Web. So do patients’ caregivers, which is a key innovation of the service, says Sean Hughes, vice president of Vree. Patients and family members also have access to a 24/7 nurse hotline.

With so many hospitals training their own staff to do transitional care, why outsource the service? “It’s very difficult to do this in a scalable way,” Mr. Hughes says. “Hospitals may have a grant or an ongoing project to focus on post-discharge care for one disease, like CHF, and they may be successful. But they are challenged when they need to scale up to include more disease states and engage patients outside of the four walls of the hospital ”

He notes that Vree has seen the most interest from hospitals that have already tried to set up such a service on their own. TransitionAdvantage may expand into other diagnoses. It may also eventually offer more comprehensive care population management for patients with chronic conditions.

Hospitals using the service pay an initiation and set-up fee, Mr. Hughes explains, along with a per-discharge charge. Because facilities label the service with their own hospital branding, patients don’t know they’re working with a third party.

More information is online at www.vreehealth.com.